Forms – Auto Client Intake Information

* = required fields

Client Information

* Name:                 
* Address:                 
Work Phone:                 
Fax:                 
Pager:                 
Date of Birth:                 
Email:                 
SSN:                 
* Home Phone:                 
Mobile Phone:                 

Spouse Information

Name:                 
Address:                 
Work Phone:                 
Fax:                 
Pager:                 
Date of Birth:                 
Email:                 
SSN:                 
Home Phone:                 
Mobile Phone:                 

Injury Information

What injuries did you sustain as a result of this accident?:


List Medical Providers/Facilities (Name, Address, Phone):


List Health Insurance Company(s) (Name, Address, Phone):


Please describe all injuries or symptoms that you continue to feel today, including any activities that are limited or prevented due to the injuries:


Have you ever had any prior medical treatment to the same areas of your body that were injured in this accident? If so, list the injury, approximate date, place, and the doctors and hospitals who treated you:

Accident Information

Date and time of accident:  

Street address or location, the names of any intersection streets or highways, the direction you were traveling and the direction any other involved vehicles were traveling:


Describe in your own words how the accident happened:


What was your speed before the impact?:


What was the speed of any other vehicle involved before the impact?:

Passengers in your Vehicle

Name:                  
Address:                  
Work Phone:                  
Date of Birth:                  
Email:                  
SSN:                  
Home Phone:                  

Name:                  
Address:                  
Work Phone:                  
Date of Birth:                  
Email:                  
SSN:                  
Home Phone:                  

Passengers in any other Vehicle(s)

Name:                  
Address:                  
Work Phone:                  
Date of Birth:                  
Email:                  
SSN:                  
Home Phone:                  

Name:                  
Address:                  
Work Phone:                  
Date of Birth:                  
Email:                  
SSN:                  
Home Phone:                  

List of Witnesses

Name:                  
Address:                  
Home Phone:                  

Name:                  
Address:                  
Home Phone:                  

Name:                  
Address:                  
Home Phone:                  

Location of Accident

Please provide us with a drawing of the location of the accident.

• Include all the lanes of travel, going in both directions, of the street that you were on, including turn lanes. Include all the lanes of travel, in both directions, including turn lanes, for any intersecting streets or alleys that are relevant to this accident.
• Locate and identify any traffic signs including stop, yield, speed limit, and any other signs or traffic control devices.
• Also draw in any physical features that may have obstructed your vision, or may have obstructed the vision of any other drivers, such as trees, bushes, buildings, or parked vehicles along the roadway.

Describe the weather conditions at the time of the accident:


Describe the lighting conditions at the time of the accident:
(was it daylight, and if so, describe the light conditions. If it was dusk or dark, state whether there were artificial lights, and whether there were artificial lights, and whether they were on or not)


Did any vehicle, including yours have on any lights prior to impact including turn signals, headlights, brake lights, taillights, fog lamps, or otherwise, and if so, describe:


Were there any skid marks, gauge marks, or debris at the scene of the accident? If so, describe what you saw, and also draw in their location on your drawing of the accident scene:


Did you or any other driver receive a ticket or criminal charge?
If so, describe what you know:


Did you or any other witness see any indication that any driver was under the influence of alcohol or drugs? If so, describe:

Loss of Income/Time from Work

Have you lost time from work or income as a result of this incident? If so, give the name, address and telephone number of your employer:

Your hourly, weekly, or monthly salary at the time of the incident:


The dates that you have missed from work:


The total amount of income you have lost since the accident:

Investigations

Has anyone investigated this accident, either police, authorities or private investigators? If so, give their name, address, telephone number and the approximate date of the investigation:

Do you have copies of any investigative reports or materials? (Yes or No):

Description of Vehicles

Your Vehicle

Make:                   
Model:                   
Serial Number:                   
Year:                   
Color:                   

Area and severity of damage:

Present Location Name:                  
Address:                  
Phone:                  

Insurance Company Name:                  
Address:                  
Phone:                  
Your Claim Number:                  

Defendant's Vehicle

Make:                  
Model:                  
Serial Number:                  
Year:                  
Color:                  

Area and severity of damage:

Present Location Name:                 
Address:                 
Phone:                 

Insurance Company Name:                 
Address:                 
Phone:                 

(If more than two vehicles were involved in the accident, please provide us with this information for each vehicle.)